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No restraint at drug-dosing New York nursing homes

Industry and government teamed up to reduce the use of dangerous anti-psychotic drugs in nursing homes — but one in three in New York City increased the pace of prescriptions

A year after a federal health agency vowed to sharply reduce the use of powerful antipsychotic drugs in nursing homes, prescriptions have declined only modestly — and dozens of New York City facilities have actually increased their use of the medications.

In May 2012, the Centers for Medicare and Medicaid Services announced an initiative to reduce antipsychotic use in nursing homes nationally 15 percent by the end of 2012. The move followed investigations by journalists in Boston and elsewhere highlighting the rampant abuse of the sometimes fatal drugs, and took the lead from an industry-driven reform campaign.

Nationally, the rate declined by less than 8 percent, and in New York City it went down by just 5.4 percent last year, newly released data reveal.

Zyprexa is just one of the anti-psychotic drugs frequently used on elderly people with dementia in nursing homes, despite FDA warnings. AP Photo/Darron Cummings

Zyprexa is just one of the anti-psychotic drugs frequently used on elderly people with dementia in nursing homes, despite FDA warnings. AP Photo/Darron Cummings

“I think it’s good that there are thousands of people that would have received the drugs and didn’t,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a nursing home resident advocacy group based in the city. “But there are still thousands of people who received the drugs and shouldn’t have.”

Antipsychotics — developed to moderate symptoms of psychosis tied to conditions like schizophrenia and bipolar disorder — have been prescribed at rates as high as 40 percent for nursing home residents without such a diagnosis. Often, nursing homes use them to pacify residents with dementia who don’t cooperate. But doing so poses significant risks to the vulnerable residents.

The Food and Drug Administration requires warning labels on powerful anti-psychotics  like Risperdal and Abilify specifically informing prescribers that elderly patients with dementia face a heightened risk of death and noting that the drug has not been approved by the FDA for such patients.

A 2012 review by Harvard and University of South Carolina physicians found that for every 100 nursing home residents who suffer from dementia and receive antipsychotics, only between nine and 25 would see any benefit. The tradeoff: one would die.

Even so, the Inspector General for the U.S. Department of Health and Human Services found that of the nearly 1.3 million prescriptions paid for by Medicare, an astonishing 88 percent went to elderly patients with dementia, in defiance of the warning. 

The numbers show reliance on antipsychotics is more common at some homes than others — and in many cases growing sharply.

Laconia Nursing Home in the Bronx, Meadow Park Rehab Health Center LLC and Brooklyn Queens Nursing Home saw their rates explode by over a third between the first and last quarter of 2012, to rates reaching as high as half of their residents receiving antipsychotics.

In all, 56 New York City homes saw their antipsychotic use grow after the campaign began. Another 105 homes either saw their rates stay flat or drop; just under half of those met the 15 percent reduction goal. Some homes made significant strides — like Grand Manor Nursing Home, which reduced its rate from 33.8 percent of patients to 22 percent during 2012.

Meadow Park Rehab Health Center administrator Ari Gluck, contacted by phone, said that he would not answer questions on antipsychotics, then hung up. Administrators at Laconia and Brooklyn Queens did not return repeated phone calls seeking comment.

The Centers for Medicare and Medicaid Services did not respond to multiple phone and email requests for comment.

New York falls in the middle of the pack among states in its rate of antipsychotic use: about 22 percent of all nursing home patients statewide were on drugs such as Abilify, Seroquel and Risperdal in the most recent reporting period.

In March 2013, New York State Commissioner of Health Nirav Shah sent a letter to nursing home administrators detailing the harms and growth in use of antipsychotic drugs, urging them to lower their numbers; he also provided materials to help homes rein in use. The letter ends, however, noting that the suggested strategies “are not mandated for adoption.”

Advocates for nursing home residents say that New York should emulate other states — such as Delaware, Kentucky, North Carolina and Massachusetts — that have reinvested fines collected from nursing homes into training and other measures to reduce the use of antipsychotics on patients with dementia.

The New York State Department of Health did not respond to requests for comment.

Industry representatives say that the numbers so far show good progress.

“Certainly we’re getting to the point of continuous improvement,” said Dick Herrick, President and CEO of the New York State Health Facilities Association, a state affiliate of the American Healthcare Association. The national group initiated the campaign and has reaffirmed its 15 percent reduction goal for 2013.

“Is it ever going to be 0? No,” he said, noting that the drugs are appropriate for some residents. But Herrick said he saw hope that the numbers would “get to a level which is more clinically sustainable.”

Patient advocates say that the small reductions are disheartening, particularly because, they argue, the goal wasn’t ambitious to begin with.

“We were concerned because we didn’t think that 15 percent was enough of a reduction. So not even being able to reach that mark is of great concern to us,” said Robyn Grant, director of public policy and advocacy for The National Consumer Voice for Quality Long-Term Care.

“The 15 percent was something that the nursing home industry put out there and proposed. My guess would be they were putting it at a rate that they thought they could accomplish, which just underscores how disappointing it is and how troubling it is that they didn’t achieve their own goal.”